Medicare Lifestyle Modification Program Demonstration

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Documents and Forms

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no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

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IC Title:	Medicare Lifestyle Modification Program Demonstration	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-289				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,000	4,500	4,500
Annual IC Time Burden (Hours)	1,500	750	750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.